Adolescent Asthma Study Interest Form

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Please fill in the following information to learn more about this study and to learn if your adolescent might be eligible to join. Pharmaceutical Research & Consulting is a clinical research office in Dallas, TX, and will only use the information you provide to share details about the study. We will never share your information. To learn more about us, please view our website at Dallas Allergy & Asthma Center (daac-prc.com)

Name *

Email *

Phone Number *

Zip Code

Please indicate which of the following best describes the adolescent with asthma interested in learning about this study:

At least 12, but less than 18 years of age. *

Yes

Diagnosed with asthma at least 12 months ago *

Yes

Currently using an inhaled corticosteroid medication (on its own, or in combination with another asthma medication. *

Yes

Over the last 12 months, has had at least 1 but no more than 3 severe asthma episodes that required additional steroid medication, an emergency department visit, or a hospital stay.
*

Yes

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